Broadbent’s inverted sign is characterized by pulsations observed in the left posterolateral chest wall that coincide with ventricular systole. Detection of these pulsations can indicate gross dilation of the left atrium, often associated with chronic mitral valve disease.

Pathophysiology

The left atrium lies posteriorly in the thoracic cavity, adjacent to the esophagus and left posterior chest wall. Left atrial enlargement—most commonly due to mitral stenosis or regurgitation—transmits systolic pulsations posteriorly. During ventricular systole, the enlarged atrium moves outward, producing palpable and sometimes visible pulsations in the left posterolateral thoracic region.

Examination technique

Patient Positioning

• Position the patient sitting upright or leaning slightly forward, exposing the left posterolateral chest wall.

Palpation

• Place your fingers and palm over areas of visible or suspected pulsation in the left posterior thorax.

• Palpate gently but firmly, feeling for rhythmic pulsations.

Auscultation

• While palpating, listen for ventricular systole with a stethoscope.

• Correlate the timing of pulsations with the cardiac cycle to confirm systolic origin.

Assessment

• Note rate, rhythm, intensity, and whether pulsations are synchronous with the apical impulse.

• Compare findings with the right side of the chest and anterior precordium to detect asymmetry.

Clinical utility

• Indicator of left atrial enlargement: Particularly in chronic mitral stenosis or mitral regurgitation.

• Noninvasive bedside clue: Supports diagnosis before echocardiography or imaging.

• Adjunct to other signs: Often assessed alongside mitral facies, diastolic murmur, and pulmonary rales.

Differential Diagnosis

Diagnostic approach

• Echocardiography: Confirms left atrial size and mitral valve pathology.

• Chest X-ray: May show enlarged left atrial silhouette.

• Electrocardiogram (ECG): Detects atrial enlargement and arrhythmias (e.g., atrial fibrillation).

• Cardiac MRI/CT: Reserved for complex structural assessment.

Management

• Address underlying cardiac disease:

  • Mitral valve repair or replacement for severe stenosis/regurgitation.

  • Rate control and anticoagulation for atrial fibrillation.

  • Diuretics and other supportive therapy for pulmonary congestion.

• Monitor hemodynamics: Especially in symptomatic patients with dyspnea, palpitations, or edema.

Pediatric considerations

• Rare in children, usually secondary to congenital mitral valve anomalies.

• Echocardiography is essential for diagnosis.

Geriatric considerations

• Older adults may present with atrial fibrillation or chronic mitral valve disease.

• Palpation may be subtle due to increased chest wall thickness or kyphoscoliosis.

Patient counseling

• Explain the significance of palpated pulsations and their association with heart enlargement.

• Emphasize importance of cardiac imaging and follow-up.

• Discuss symptom monitoring, including dyspnea, palpitations, or fatigue.

Conclusion

Broadbent’s inverted sign is a valuable clinical indicator of left atrial enlargement. While not diagnostic alone, it serves as an important bedside clue, particularly in chronic mitral valve disease. Accurate detection enhances early recognition and supports timely intervention.

References

1. Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia: Elsevier; 2022.

2. McCance KL, Huether SE. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 8th ed. St. Louis: Mosby Elsevier; 2021.

3. Butany J, et al. Cardiovascular Pathology. 5th ed. London: Elsevier; 2018.

4. Braunwald E, Zipes DP, Libby P. Braunwald’s Heart Disease Review and Assessment. 11th ed. Philadelphia: Elsevier; 2021.